Clinical Practice Guidelines: Medical/Sepsis

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Clinical Practice Guidelines: Medical/Sepsis
Clinical Practice Guidelines: Medical/Sepsis
Disclaimer and copyright
©2016 Queensland Government
All rights reserved. Without limiting the reservation of copyright, no person shall reproduce, store in a
retrieval system or transmit in any form, or by any means, part or the whole of the Queensland Ambulance
Service (‘QAS’) Clinical practice manual (‘CPM’) without the priorwritten permission of the Commissioner.
The QAS accepts no responsibility for any modification, redistribution or use of the CPM or any part
thereof. The CPM is expressly intended for use by QAS paramedics whenperforming duties and delivering
ambulance services for, and on behalf of, the QAS.
Under no circumstances will the QAS, its employees or agents, be liable for any loss, injury, claim, liability
or damages of any kind resulting from the unauthorised use of, or reliance upon the CPM or its contents.
While effort has been made to contact all copyright owners this has not always been possible. The QAS
would welcome notification from any copyright holder who has been omitted or incorrectly acknowledged.
All feedback and suggestions are welcome, please forward to:
[email protected]
Date
April, 2016
Purpose
Scope
To ensure consistent management of patients with Sepsis.
Applies to all QAS clinical staff.
Author
Clinical Quality & Patient Safety Unit, QAS
Review date
April, 2018
URL
https://ambulance.qld.gov.au/clinical.html
This work is licensed under the Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0
International License. To view a copy of this license,
visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Sepsis
April, 2016
Fluid resuscitation boluses with sodium chloride 0.9% of 250–500 mL (10–20 mL/kg) should be considered. Additional fluid boluses should be administered if there is no improvement of vital signs and no signs of pulmonary oedema. If there are signs of organ hypoperfusion despite
appropriate fluid resuscitation, consider administration of a vasopressor
and aim for a Mean Arterial Pressure (MAP) > 65 mmHg.[9]
Sepsis is a syndrome of infection complicated by systemic inflammation and can result in organ dysfunction, shock and death.
Sepsis remains a major cause of death worldwide and creates a large
burden on communities and hospital systems with an associated high
economic cost. Severe sepsis mortality exceeds that of AMI, stroke and
trauma. Sepsis mortality rates can be as high as 50% in severe sepsis
and up to 80% in septic shock.[1-3] Sepsis is a complex process that can progress along a continuum from sepsis, through severe sepsis and onto septic shock, with no clear delineation between these phases.
Overall, respiratory infections account for approximately half of all cases of sepsis. The next most common causes are genitourinary and abdominal sources of infection.[3-5]
UNCONTROLLED WHEN PRINTED
Clinical features
UNCONTROLLED WHEN PRINTED
Diagnosis of sepsis requires the presence of a presumed or known site of infection with evidence of Systematic
Inflammatory Response Syndrome (SIRS) characterised
clinically in adults by two or more of:
Sepsis has the potential to affect anyone but risk factors are related to
both a patient’s predisposition to infection and the likelihood of acute
organ dysfunction if infection develops. Additionally, the incidence of
sepsis is higher in infants and the elderly and higher in males than in
females.
• Temperature > 38.3 or < 36°C
• Heart rate > 90 min
UNCONTROLLED WHEN PRINTED
Key components in the pre-hospital management of sepsis
are:[6]
• Early identification
•
Respiratory rate > 20 min
•
BGL > 6.6 mmol/L (unless diabetic)
•
Acutely altered mental status
Severe sepsis is identified by the presence of sepsis and
evidence of organ hypoperfusion or dysfunction and is
characterised clinically in adults by one or more of:
• Early oxygenation
• Early haemodynamic resuscitation[7]
• Hospital notification[8]
UNCONTROLLED WHEN PRINTED
It is critical to prevent end organ hypoxia in the septic patient. For
respiratory distress consider the early application of high flow oxygen
therapy and the possibility of the need for positive pressure ventilation
(i.e. BVM/CPAP) and the possibility of an advanced airway in cases of altered level of consciousness or severe respiratory compromise and/or failure.
Figure 2.24
•
Blood pressure systolic < 90 or MAP < 65 mmHg
•
Oxygen saturations < 90%
•
Not passed urine for > 8 hours
•
Prolonged bleeding from minor injury or gums.[10]
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96
Risk Assessment
• One of the hypothesised reasons for the misdiagnosis of severe sepsis and septic shock is because the initial
presentation is often non-specific and its severity ambiguous.[10]
CPG: Paramedic Safety
CPG: Standard Cares
Manage as per:
UNCONTROLLED WHEN PRINTED
• Diagnosis requires the presence of a presumed or known [3]
site of infection which may be bacterial, viral, fungal or even
parasitic in origin.[11]
Suspected meningoccocal sepsis?
• The most common presenting symptom in sepsis is tachypnoea.[12]
Y
• CPG: Meningococcal
septicaemia
N
Consider:
Suspected severe sepsis
or septic shock?
UNCONTROLLED WHEN PRINTED
e
Additional information
• Sepsis should be suspected in any generally unwell patient that is potentially immunosuppressed (e.g. recent chemotherapy, on
immunosuppressive medications like methotrexate and prednisolone, history of chronic liver or renal disease)
N
• Antipyretic
• IV fluid
Y
Consider:
• Oxygen
• IV fluid
UNCONTROLLED WHEN PRINTED
• Fluid overload may be difficult to detect if the patient has sepsis-induced
acute lung injury and Acute Respiratory Distress Syndrome (ARDS). Response to interventions should be constantly monitored through patient vital signs.
• A child who is bradycardic and/or hypotensive is pre-arrest and requires
immediate intervention.
• Adrenaline (epinephrine)
Transport to hospital
Pre-notify as appropriate
UNCONTROLLED WHEN PRINTED
• BGL should be regularly monitored and maintained especially in children.
• Whilst fever is commonly associated with sepsis, hypothermia is a worrying
sign that is associated with higher morbidity particularly in the elderly.[13]
• Paediatric and elderly patients may present with only mild hyperthermia in the setting of sepsis
Note: Officers are only to perform procedures for which they
have received specific training and authorisation by the QAS.
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